CAJ | 학술논문

结合我国近年来各医疗机构电子病历应用情况，分析目前电子病历归档现状、归档方法、归档内容、电子签名技术、政策法规层面上的不适应，医疗行业工作性质影响电子病历实施等因素，结合临床科室应用电子病历的反馈。得出结论是现阶段电子病历技术、电子病历归档技术仍不够成熟，根据临床工作规范和流程，电子病历的研发应以临床实践为核心，以病案管理为主线，连贯医院环节，以促进电子病历的深入研究，直至取消纸质病案。但一定时期内纸质病案还不能取消。
결합아국근년래각의료궤구전자병력응용정황，분석목전전자병력귀당현상、귀당방법、귀당내용、전자첨명기술、정책법규층면상적불괄응，의료행업공작성질영향전자병력실시등인소，결합림상과실응용전자병력적반궤。득출결론시현계단전자병력기술、전자병력귀당기술잉불구성숙，근거림상공작규범화류정，전자병력적연발응이림상실천위핵심，이병안관리위주선，련관의원배절，이촉진전자병력적심입연구，직지취소지질병안。단일정시기내지질병안환불능취소。
To analyze filing status, archive method, archive content, electronic signature technology, policies and regulations level does not adapt. The influence factors of health care industry work nature on the implementation of electronic medical records based on the application situation of electronic medical records in recent years. At present technology of electronic medical records and electronic medical records archive technology is still not mature enough, according to the clinical work standard and process, research and development of electronic medical records should be based on clinical practice, and with the concept of medical record management, make coherent hospital link, in order to promote the in-depth study of electronic medical records, until cancel paper medical records. But paper medical records during a certain period can't cancel.